3A|
2C|
2B|
2A|
1B|
SUMMARY REVIEW/ORAL MEDICINE
1A|
Value of prophylactic antibiotics for invasive dental procedures unclear Abstracted from Glenny AM, Oliver R, Roberts GJ, Hooper L, Worthington HV. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database of Syst Rev 2013; 10: Art. No: CD003813. DOI: 10.1002/14651858.CD003813.pub4. Address for correspondence: Luisa Fernandez Mauleffinch, Review Group Co-ordinator, Cochrane Oral Health Group, MANDEC, School of Dentistry, University of Manchester, Higher Cambridge Street, Manchester, M15 6FH, UK. E-mail: [email protected].
Question: Are prophylactic antibiotics required before invasive dental procedures in people at risk or at high risk of bacterial endocarditis?
Commentary The recommendation for antibiotic prophylaxis prior to dental procedures for patients at high risk for bacterial endocarditis is a controversial topic worldwide and has been under debate for the last few decades.
Data sources The Cochrane Oral Health Group’s Trials Register, the
Evidence-based research was used to revise older guidelines, allow-
Cochrane Central Register of Controlled Trials (CENTRAL), Medline,
ing practitioners and patients vital information to make informed
Embase, the US National Institutes of Health Trials Register and the
decisions regarding antibiotic prophylaxis. Part of the information
metaRegister of Controlled Trials.
included in the revision addresses the rare but possible anaphylaxis
Study selection Randomised controlled trials (RCTs) and controlled
response to the single dose antibiotic.
clinical trials (CCTs) would be included where available. Due to the low
This systematic review was published after the American Heart
incidence of bacterial endocarditis it was anticipated that few such trials
Association (AHA)1 published their reviewed guidelines in 2007 and
would be found. Cohort and case-control studies were included where
the National Institute for Health and Care Excellence (NICE) in the
suitably matched control or comparison groups had been studied.
UK revised their guidelines in 2008 for prevention of infective bac-
Data extraction and synthesis Two review authors independently
terial endocarditis.2 This systematic review used appropriate search
selected studies for inclusion then assessed risk of bias and extracted
strategies in that they accepted case controlled studies in their inclu-
data from the included study.
sion criteria. A randomised clinical trial would be questionable to
Results Only one case controlled study met the inclusion criteria. It
carry out in some parts of the world since giving or not giving anti-
collected all the cases of endocarditis in the Netherlands over two years,
biotics to prevent bacterial endocarditis in vulnerable patients may
finding a total of 24 people who developed endocarditis within 180
result in a fatal outcome.
days of an invasive dental procedure, definitely requiring prophylaxis
As a Cochrane review the search, selection of articles and the
according to current guidelines, and who were at increased risk of
critical appraisal were done by more than one reviewer and fol-
endocarditis due to a pre-existing cardiac problem. This study included
lowed the correct protocols on conducting a systematic review.
participants who died because of the endocarditis (using proxies).
One article selected for final discussion was a case control study
Controls attended local cardiology outpatient clinics for similar cardiac
done in 1992. This study was conducted in the Netherlands and
problems, had undergone an invasive dental procedure within the
was assessed for bias and quality, which was referenced in the AHA
past 180 days, and were matched by age with the cases. No significant
and NICE guidelines.
effect of penicillin prophylaxis on the incidence of endocarditis could
Antibiotic prophylaxis is still a polemic topic in dentistry. For
be seen. No data were found on other outcomes.
many years it was believed that bacterial endocarditis was caused by
Conclusions There remains no evidence that antibiotic prophylaxis is
the introduction of oral bacteria systemically and for those patients
either effective or ineffective against bacterial endocarditis in people
that had certain cardiac conditions the risk was high. As a result, pre-
considered at risk who are about to undergo an invasive dental
medication with antibiotic prophylaxis was required prior to under-
procedure. It is not clear whether the potential harms and costs of
going invasive dental therapy.
penicillin administration outweigh any beneficial effect. Ethically,
The American Heart Association (AHA) revised those recommenda-
practitioners need to discuss the potential benefits and harms of
tions and many of the previously pre-medicated conditions were no
antibiotic prophylaxis with their patients before a decision is made
longer considered for antibiotic coverage prior to dental treatment.
about administration.
Interestingly, The National Institute for Health and Care Excellence (NICE) and the American Heart Association differ in their recommen-
This paper is based on a Cochrane Review published in the Cochrane Library 2013, issue 10 (see www.thecochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and the Cochrane Library should be consulted for the most recent version of the review.
dations for antibiotic premedication. The AHA recommends that certain conditions be pre-medicated, whereas NICE determined that no antibiotic coverage is needed prior to any dental procedure. A study in England, which analysed the impact of the NICE guidelines specifically, looked at antibiotic pre-medication for
12
© EBD 2014:15.1 © 2014 Macmillan Publishers Limited. All rights reserved
ORAL MEDICINE high-risk patients undergoing invasive dental procedures. They examined the incidence of infective endocarditis and concluded
Glenn K Rochlen and Analia Veitz Keenan
that there was no significant increase in the number of cases.
NYU College of Dentistry, New York, USA
The authors suggested that ongoing data monitoring is needed to
such as eating and oral hygiene practices among those factors. This
1. Wilson W, Taubert KA, Gewitz M, et al. AHA Guideline: Prevention of Infective Endocarditis: Guidelines From the American Heart Association: A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes. Circulation 2007; 116: 1736-1754. Published online before print April 19 2007, doi:10.1161/CIRCULATIONAHA.106.183095 2. Prophylaxis Against Infective Endocarditis: Antimicrobial Prophylaxis Against Infective Endocarditis in Adults and Children Undergoing Interventional Procedures. CG64 National Institute for Health and Care Excellence London: 2008 3. Thornhill MH, Dayer MJ, Forde JM, et al. Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study. BMJ 2011; 342: d2392. doi: 10.1136/bmj.d2392
further supports our role in advocating good oral home care.
Evidence-Based Dentistry (2014), 15, 12-13. doi: 10.1038/sj.ebd.6400983
determine if antibiotic prophylaxis has a role in protecting a small group of patients at higher risk.3 The challenge each practitioner encounters is the interpretation of the evidence obtained and its clinical application. Adopting a protocol to follow is further complicated by the use of different guidelines in other parts of the world. In addition to invasive dental procedures as a risk for bacterial endocarditis, we need to consider daily activities
13
www.nature.com/ebd © 2014 Macmillan Publishers Limited. All rights reserved
2C|
2B|
2A|
1B|
SUMMARY REVIEW/ORAL MEDICINE
1A|
Value of prophylactic antibiotics for invasive dental procedures unclear Abstracted from Glenny AM, Oliver R, Roberts GJ, Hooper L, Worthington HV. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database of Syst Rev 2013; 10: Art. No: CD003813. DOI: 10.1002/14651858.CD003813.pub4. Address for correspondence: Luisa Fernandez Mauleffinch, Review Group Co-ordinator, Cochrane Oral Health Group, MANDEC, School of Dentistry, University of Manchester, Higher Cambridge Street, Manchester, M15 6FH, UK. E-mail: [email protected].
Question: Are prophylactic antibiotics required before invasive dental procedures in people at risk or at high risk of bacterial endocarditis?
Commentary The recommendation for antibiotic prophylaxis prior to dental procedures for patients at high risk for bacterial endocarditis is a controversial topic worldwide and has been under debate for the last few decades.
Data sources The Cochrane Oral Health Group’s Trials Register, the
Evidence-based research was used to revise older guidelines, allow-
Cochrane Central Register of Controlled Trials (CENTRAL), Medline,
ing practitioners and patients vital information to make informed
Embase, the US National Institutes of Health Trials Register and the
decisions regarding antibiotic prophylaxis. Part of the information
metaRegister of Controlled Trials.
included in the revision addresses the rare but possible anaphylaxis
Study selection Randomised controlled trials (RCTs) and controlled
response to the single dose antibiotic.
clinical trials (CCTs) would be included where available. Due to the low
This systematic review was published after the American Heart
incidence of bacterial endocarditis it was anticipated that few such trials
Association (AHA)1 published their reviewed guidelines in 2007 and
would be found. Cohort and case-control studies were included where
the National Institute for Health and Care Excellence (NICE) in the
suitably matched control or comparison groups had been studied.
UK revised their guidelines in 2008 for prevention of infective bac-
Data extraction and synthesis Two review authors independently
terial endocarditis.2 This systematic review used appropriate search
selected studies for inclusion then assessed risk of bias and extracted
strategies in that they accepted case controlled studies in their inclu-
data from the included study.
sion criteria. A randomised clinical trial would be questionable to
Results Only one case controlled study met the inclusion criteria. It
carry out in some parts of the world since giving or not giving anti-
collected all the cases of endocarditis in the Netherlands over two years,
biotics to prevent bacterial endocarditis in vulnerable patients may
finding a total of 24 people who developed endocarditis within 180
result in a fatal outcome.
days of an invasive dental procedure, definitely requiring prophylaxis
As a Cochrane review the search, selection of articles and the
according to current guidelines, and who were at increased risk of
critical appraisal were done by more than one reviewer and fol-
endocarditis due to a pre-existing cardiac problem. This study included
lowed the correct protocols on conducting a systematic review.
participants who died because of the endocarditis (using proxies).
One article selected for final discussion was a case control study
Controls attended local cardiology outpatient clinics for similar cardiac
done in 1992. This study was conducted in the Netherlands and
problems, had undergone an invasive dental procedure within the
was assessed for bias and quality, which was referenced in the AHA
past 180 days, and were matched by age with the cases. No significant
and NICE guidelines.
effect of penicillin prophylaxis on the incidence of endocarditis could
Antibiotic prophylaxis is still a polemic topic in dentistry. For
be seen. No data were found on other outcomes.
many years it was believed that bacterial endocarditis was caused by
Conclusions There remains no evidence that antibiotic prophylaxis is
the introduction of oral bacteria systemically and for those patients
either effective or ineffective against bacterial endocarditis in people
that had certain cardiac conditions the risk was high. As a result, pre-
considered at risk who are about to undergo an invasive dental
medication with antibiotic prophylaxis was required prior to under-
procedure. It is not clear whether the potential harms and costs of
going invasive dental therapy.
penicillin administration outweigh any beneficial effect. Ethically,
The American Heart Association (AHA) revised those recommenda-
practitioners need to discuss the potential benefits and harms of
tions and many of the previously pre-medicated conditions were no
antibiotic prophylaxis with their patients before a decision is made
longer considered for antibiotic coverage prior to dental treatment.
about administration.
Interestingly, The National Institute for Health and Care Excellence (NICE) and the American Heart Association differ in their recommen-
This paper is based on a Cochrane Review published in the Cochrane Library 2013, issue 10 (see www.thecochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and the Cochrane Library should be consulted for the most recent version of the review.
dations for antibiotic premedication. The AHA recommends that certain conditions be pre-medicated, whereas NICE determined that no antibiotic coverage is needed prior to any dental procedure. A study in England, which analysed the impact of the NICE guidelines specifically, looked at antibiotic pre-medication for
12
© EBD 2014:15.1 © 2014 Macmillan Publishers Limited. All rights reserved
ORAL MEDICINE high-risk patients undergoing invasive dental procedures. They examined the incidence of infective endocarditis and concluded
Glenn K Rochlen and Analia Veitz Keenan
that there was no significant increase in the number of cases.
NYU College of Dentistry, New York, USA
The authors suggested that ongoing data monitoring is needed to
such as eating and oral hygiene practices among those factors. This
1. Wilson W, Taubert KA, Gewitz M, et al. AHA Guideline: Prevention of Infective Endocarditis: Guidelines From the American Heart Association: A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes. Circulation 2007; 116: 1736-1754. Published online before print April 19 2007, doi:10.1161/CIRCULATIONAHA.106.183095 2. Prophylaxis Against Infective Endocarditis: Antimicrobial Prophylaxis Against Infective Endocarditis in Adults and Children Undergoing Interventional Procedures. CG64 National Institute for Health and Care Excellence London: 2008 3. Thornhill MH, Dayer MJ, Forde JM, et al. Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study. BMJ 2011; 342: d2392. doi: 10.1136/bmj.d2392
further supports our role in advocating good oral home care.
Evidence-Based Dentistry (2014), 15, 12-13. doi: 10.1038/sj.ebd.6400983
determine if antibiotic prophylaxis has a role in protecting a small group of patients at higher risk.3 The challenge each practitioner encounters is the interpretation of the evidence obtained and its clinical application. Adopting a protocol to follow is further complicated by the use of different guidelines in other parts of the world. In addition to invasive dental procedures as a risk for bacterial endocarditis, we need to consider daily activities
13
www.nature.com/ebd © 2014 Macmillan Publishers Limited. All rights reserved
